Credit Card Authorization Form

Please fill out the credit card authorization form below to pay for dinner, gift a bottle of wine to a guest, or something else.

"*" indicates required fields

To Stella Burlingame ATTN:

Last Name

Your First Name

Your Last Name

Email*

Date*

Phone/Mobile*

I authorize Stella Burlingame to charge my credit card according to the details below. I guarantee full payment of the account as described

Yes

Amount to Charge $ (22% Gratuity will placed on all purchases)

Reason For Charge*

Reservation First Name

Reservation Last Name

Reservation Date

Reservation Time

Credit Card*

Configuration Required: To use the Stripe field, please configure your Stripe Settings.

By Typing Your Name In here – You are signing this form to be processed.*

Home/Mobile Phone*

Work/Office/Secondary Number

Download PDF Form INSTEAD

Please fill out the credit card authorization form below to pay for dinner, gift a bottle of wine to a guest, or something else.

To Stella Burlingame ATTN:

Last Name

Your First Name

Your Last Name

Email*

Date / Time*

Phone/Mobile*

I authorize Stella Burlingame to charge my credit card according to the details below. I guarantee full payment of the account as described

Yes

Amount to Charge $ (22% Gratuity will placed on all purchases)

Please Attach a Copy of the Front & Back of your Credit Card Upload a file or drag and drop. jpg, jpeg, jpe, png, avif, webp up to 10MB

Reason For Charge*

Reservation First Name

Reservation Last Name

Reservation Date

Reservation Time

Charge to:

AMEX

Mastercard

Visa

Diners Club

Card Number

EXP

CSV

By Typing Your Name In here – You are signing this form to be processed.*

CC Zip Code

Home/Mobile Phone*

Work/Office/Secondary Number

Download PDF Form INSTEAD

Credit Card Authorization Form

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